Whac-A-Mole, Anyone? Medicare & Medicaid Challenges

By Jim Stephenson

Jul 01, 2011

Do you ever feel like as soon as you get one reimbursement issue
under control, two more pop up?

With Medicare you have audits around every corner, the elimination of
the least costly alternative policy, competitive bidding looming over the
heads of most major metropolitan areas, and capped rental for low-end
power wheelchairs, to name a few.

Then there are Medicaid programs constantly pursuing cost savings by
any means necessary. Lowlights include state-level competitive bidding
programs, potential provision of used equipment, attempts at limiting
benefits for equipment to those less than 21 years of age… and my
favorite: insisting that a Group 2 power wheelchair is sufficient to meet
the needs of people with complex medical conditions.

Government funding has become like a never-ending game of Whac-a-Mole. Medical suppliers have to be more like firefighters than business
people nowadays.

Medicaid Update: Hunting for Cash in All the
Wrong Places

State Medicaid programs are strapped for cash, no doubt, but they are
cutting spending in ways that are detrimental to the very people they
serve — their beneficiaries.

Rather than consider fixing internal procedural inefficiencies to save
money, it is easier to say, “This particular population is no longer covered,”
or “We aren’t paying for new equipment anymore.”

If the cost-savings challenges aren’t enough, there is always a good
administrative issue or two to slow down receipt of your money. Whether
it’s non-acceptance of the universal HCPCS coding system mandated
by HIPAA more than eight years ago, or the untimely approval of prior
authorizations, you’re bound to run into an obstacle somewhere along
the way. And when you finally snip through all the red tape and jump
through all the hoops, you can look forward to working with a payment
methodology that may be enough to help you break even.

Unfortunately, there is no easy resolution other than educating and
lobbying state legislators to make necessary changes and to vote against
bad ideas. Of course, this requires time away from the office and more
money spent to protect your business, as well the benefits of those you
serve. It’s a vicious circle, but necessary in the current reimbursement
environment.

Medicare Update: Audits & Least Costly
Alternative Change

Audits have become a major concern for nearly all medical equipment
suppliers. From pre- and post-pay reviews to CERT, RAC and ZPIC audits,
it’s a wonder any claims make it through the system without extra
attention.

I cannot recall a time when providers have been under this much scrutiny.
Cash flow is the biggest concern: Not only does the added review
time slow down the payment process, but even when your claim is paid,
there is no guarantee you’ll get to keep the money in the long run.

The best advice at this point is to not cut any corners. Make sure you’ve
done your due diligence by double-checking yourself before submitting
claims. Medical necessity documentation is the huge focus, and while it
can be challenging to get every “i” dotted and “t” crossed, your getting
paid and staying paid relies on it under the
current circumstances.

Medicare dealt our industry another
blow on Feb. 4 by eliminating the least
costly alternative language from its
medical policies. This is especially troubling
in the power mobility world,
because the change in policy also disallowed
the option to upgrade to Group 2
scooters, Group 2 power wheelchairs
with a seat elevator, and Group 4 power
wheelchairs. This essentially took away a
patient’s freedom of choice by not even
allowing them to pay out of pocket for
products they want, but don’t qualify for.

Due to industry outcry, the ability to
provide an upgrade was restored on June 1
for Group 2 scooters and Group 4 power
wheelchairs, which leaves a window of
nearly four months where beneficiaries
were not able to receive a requested
upgrade. Group 2 power wheelchairs with
a seat elevator were not included in this
update and have since been labeled statutorily
non-covered. For all intents and purposes, this ruling will turn
codes K0830 and K0831 into retail items once the trickle-down effect
starts hitting other funding sources.

Competitive Bidding Repeal Efforts Gain Strength

On March 11, Rep. Glenn Thompson (R-Pa.) and Rep. Jason Altmire (D-Pa.)
officially introduced a bipartisan House bill to repeal competitive bidding.
H.R. 1041 is also known as the Fairness in Medicare Bidding Act
At press time, there were 107 co-sponsors signed on. The industry
needs as much Congressional support as it can get, so you can help take
this “atrocious” (to quote University of Maryland economics professor
Peter Cramton) program down by making sure your state representation
supports the bill.

You can get talking points, issue papers and other supporting materials
to help educate your representatives on the repeal by visiting the
American Association for Homecare Web site at aahomecare.org. It would be
ideal to get the program repealed before it impacts the next 91 cities
(bidding for round 2 of the program is slated to begin in early 2012).

A point that is important for suppliers to know is even if you are not
located in or don’t do business in any of the first 100 cities involved in
competitive bidding, the program will eventually impact you negatively
if it isn’t stopped.

This article originally appeared in the July 2011 issue of Mobility Management.